chronic disease prevention network€¦ · funding opportunity overview 1. description: the wyoming...

Chronic Disease Prevention Program | RFA No. CDPP007 | May 3, 2019

STATE OF WYOMING

DEPARTMENT OF HEALTH

PUBLIC HEALTH DIVISION

6101 YELLOWSTONE ROAD, SUITE 420

CHEYENNE, WY 82002

REQUEST FOR APPLICATION

NO. CDPP007

CHRONIC DISEASE PREVENTION NETWORK REGIONAL COORDINATORS

OPENING DATE

April 1, 2019

APPLICATION SUBMISSION CLOSING DATE

May 3, 2019

11:59 PM (MST)

DEPARTMENT OF HEALTH REPRESENTATIVE: Melissa Payne

TELEPHONE NO.: (307) 777-3579


TABLE OF CONTENTS

TABLE OF CONTENTS .................................................................................................................................. 2

FUNDING OPPORTUNITY OVERVIEW ................................................................................................... 3

1. DESCRIPTION: .......................................................................................................................................... 3

2. RATIONALE:.............................................................................................................................................. 3

3. ELIGIBLE APPLICANTS: ....................................................................................................................... 5

4. REGIONS AND FUNDING LIMITS: ..................................................................................................... 5

5. RFA APPLICATION DETAILS: ............................................................................................................. 6

6. TERM OF CONTRACT: ........................................................................................................................... 7

7. NON-APPROVED USE OF FUNDS: ..................................................................................................... 7

8. TIMELINE: ................................................................................................................................................. 8

9. RESERVED RIGHTS: ............................................................................................................................... 8

10. APPLICATION REVIEW PROCESS: ................................................................................................... 9

APPLICATION ............................................................................................................................................... 10

1. GENERAL FORMAT REQUIREMENTS: ......................................................................................... 10

2. APPLICATION REQUIREMENTS: ................................................................................................... 10

APPENDIX A: ................................................................................................................................................. 18


FUNDING OPPORTUNITY OVERVIEW

1. DESCRIPTION:

The Wyoming Department of Health (WDH), Chronic Disease Prevention Program (CDPP) is

accepting applications for regional contractors throughout Wyoming to coordinate chronic

disease prevention and management at the regional level. The selected applicant will be required

to hire and/or manage regional chronic disease prevention personnel, provide necessary fiscal

functions, and oversee all needed administrative and human resource support including staff

training and collaboration with the CDPP and various stakeholders.

2. RATIONALE:

This Request for Applications (RFA) is competitive, and will support the CDPP in implementing

evidence-based strategies to prevent and manage cardiovascular disease (CVD) and type 2

diabetes in high-burden populations/communities, contributing to improved health outcomes.

High burden populations are those affected disproportionately by high blood pressure, high

blood cholesterol, diabetes, or prediabetes due to socioeconomic or other characteristics,

including inadequate access to care, poor quality of care, or low income. The evidence-based

strategies are separated into two categories. Category A strategies focus on diabetes management

and type 2 diabetes prevention. Category B strategies focus on CVD prevention and

management. Complementary strategies should be addressed in a way that benefits both people

with prediabetes or diabetes and people with high blood pressure and with or at risk for high

blood cholesterol.

Diabetes is the seventh leading cause of death in the United States; the number one cause of

kidney failure, lower-limb amputations, and adult-onset blindness; and a leading cause of heart

disease and stroke. A large body of evidence supports the effectiveness of diabetes self-

management education and support (DSMES) in improving health outcomes (A1c, systolic blood

pressure), lowering medication use, and decreasing hospitalizations and other healthcare costs

for people with diabetes. However, DSMES utilization rates are low.

Approximately 84 million Americans, or one in three adults, have prediabetes, a health condition

characterized by blood glucose levels that are higher than normal but not high enough to be

diagnosed as diabetes. People with prediabetes have an increased risk of developing type 2

diabetes, heart disease, and stroke. Prediabetes is treatable, but only about 10 percent of people

who have it are aware that they do. The Centers for Disease Control and Prevention (CDC) -led

National Diabetes Prevention Program (National DPP) is a partnership of public and private

organizations working collectively to build the infrastructure for nationwide delivery of an

evidence-based lifestyle change program for adults with prediabetes to prevent or delay onset of

type 2 diabetes. The lifestyle change program is founded on the science of the Diabetes

Prevention Program research study, and several translation studies that followed, which showed

that making modest behavior changes helped participants with prediabetes lose five to seven

percent of their body weight and reduce their risk of developing type 2 diabetes by 58 percent.

The program has been shown to be cost effective and can be cost saving.


Heart disease is the leading cause of death, and stroke is the fifth leading cause of death, in the

United States. CVD, including heart disease, stroke, and other vascular diseases, accounts for

more than 800,000, or about one in three, deaths per year, and around one in five who die from

CVD are younger than 65 years. CVD is costly, with an estimated one in seven healthcare dollars

spent on CVD (about 15%). Hypertension is a primary risk factor for CVD. While control of

hypertension, reflective of individual and system-level improvements, has been increasing, less

than half of those with hypertension are controlled. Interventions to support patient engagement,

prevention, and health system improvements need to be maximized to improve hypertension

management. High blood cholesterol is another primary risk factor for CVD. Several modifiable

health behaviors can lower cholesterol, including eating a healthy diet, losing weight, and being

physically active. Behavior modification improvements and health systems advances are needed

to reduce the need for treatment and close the gap in treatment across the population. Health

system interventions may include use of team-based care and community health workers,

electronic health record alignment with national guidelines, improved medication adherence, and

interventions supporting better continuity of care across healthcare settings.

Applicants are encouraged to implement the Category A and Category B strategies listed below

in high burden areas/communities. Strategies should be addressed in a way that benefits both

people with prediabetes or diabetes and people with high blood pressure and with or at risk for

high blood cholesterol.

Category A:

Diabetes Management: Improve Care and Management of People with Diabetes

A.1. Improve access to and participation in American Association of Diabetes-recognized and

American Association of Diabetes Educators-accredited DSMES programs in underserved areas.

A.2. Increase engagement of pharmacists in the provision of medication management or DSMES

for people with diabetes.

Type 2 Diabetes Prevention: Improve access to, participation in, and coverage for the National

Diabetes Prevention Program (National DPP) lifestyle change program for people with

prediabetes, particularly in underserved areas.

A.3. Assist healthcare organizations in implementing systems to identify people with prediabetes

and refer them to CDC-recognized lifestyle change programs for type 2 diabetes prevention.

A.4. Collaborate with payers and relevant public and private sector organizations within the state

to expand availability of the National DPP as a covered benefit for one or more of the following

groups: Medicaid beneficiaries; state/public employees; employees of private sector

organizations.

A.5. Implement strategies to increase enrollment in CDC-recognized lifestyle change programs.


Category B:

Track and Monitor Clinical Measures Shown to Improve Healthcare Quality and Identify

Patients with Hypertension

B.1. Promote the adoption of evidence-based quality measurement at the provider level (e.g., use

dashboard measures to monitor healthcare disparities and implement activities to eliminate

healthcare disparities).

Implement Team-Based Care for Patients with High Blood Pressure and High Blood Cholesterol

B.2. Support engagement of non-physician team members (e.g., nurses, nurse practitioners,

pharmacists, nutritionists, physical therapists, social workers) in hypertension and cholesterol

management in clinical settings.

B.3. Promote the adoption of Medication Therapy Management (MTM) between pharmacists

and physicians for the purpose of managing high blood pressure, high blood cholesterol, and

lifestyle modification.

Link Community Resources and Clinical Services that Support Systematic Referrals, Self-

Management, and Lifestyle Change for Patients with High Blood Pressure and High Blood

Cholesterol

B.4. Facilitate use of self-measured blood pressure monitoring (SMBP) with clinical support

among adults with hypertension.

B.5. Implement systems to facilitate systematic referral of adults with hypertension and/or high

blood cholesterol to community programs/resources.

3. ELIGIBLE APPLICANTS:

The CDPP is seeking proposals from Wyoming organizations that are in good standing with the

State of Wyoming and have a desire and ability to reduce the prevalence and burden of chronic

disease in the state of Wyoming. Health systems are encouraged to apply. Individuals are also

eligible to apply, provided they have demonstrated capacity to accomplish the requirements

listed in this RFA. Preference may be given to organizations with strong relationships with

health systems. All applicants who are not individuals must have an active DUNS number and be

registered with SAM.gov. Sole applicants for a region will not be guaranteed the grant award.

4. REGIONS AND FUNDING LIMITS:

The six (6) regions are outlined in the following table. Organizations should identify which region

they are applying for within both the proposed project plan and proposed work plan portions of

the application. Organizations applying for multiple regions must have staff physically located

within each region. Separate applications must be submitted for each region.


Region Counties Maximum Two-Year

Funding Amount

I Albany, Goshen, Laramie, Platte $196,800

II Carbon, Converse, Natrona, Niobrara $196,800

III Campbell, Crook, Johnson, Sheridan, Weston $196,800

IV Big Horn, Fremont, Hot Springs, Park, Washakie $196,800

V Lincoln, Sublette, Sweetwater, Teton, Uinta $196,800

VI Wind River Indian Reservation $120,000

The funding for this contract is made available through federal funds provided by the CDC. The

actual funding amounts awarded will be based on the strength of the application and the work

plan submitted and may be higher or lower than the amounts requested.

5. RFA APPLICATION DETAILS:

Applications will be accepted through May 3, 2019 at 11:59 PM Mountain Standard Time. Only

completed applications will be accepted. Requests for deadline extensions will not be

considered.

QUESTIONS:

Applicants will be allowed the opportunity to email questions regarding this funding opportunity

through April 23, 2019. All questions should be submitted to Melissa Payne, Chronic Disease

Prevention Program Manager, at [email protected]. Answers to all questions will be

posted publically on the CDPP website. Please include “RFA: Question” in the email subject

line.

OPTIONAL BIDDERS’ CALL

Applicants will have the option to participate in an optional bidders’ call. The call will take

place on April 15, 2019 from 11:00 AM to 12:00 PM. Register in advance for the bidders’ call

at: https://zoom.us/meeting/register/80fab36a424aa68b7c24e00bf0acd2b8. After registering,

you will receive a confirmation email containing information about joining the call.

SUBMITTING COMPLETED APPLICATION:

Applicants should submit a completed application via email to Melissa Payne, Chronic Disease

Prevention Program Manager, at [email protected]. Please submit a single PDF

document and include “RFA: Application Submission” in the email subject line. Applications

must be submitted by May 3, 2019 at 11:59 PM Mountain Standard Time.

mailto:[email protected]

https://zoom.us/meeting/register/80fab36a424aa68b7c24e00bf0acd2b8

mailto:[email protected]


Following submission, applicants will receive a confirmation email verifying receipt of the

application within 2 business days.

NOTIFICATION OF AWARD OR NONAWARD

Applicants will receive written notice by May 24, 2019, as to whether the application has been

approved to be funded wholly, in part, or not funded. Selected applicants will begin the contract

process with the CDPP. All funded activities must be completed within the term of the contract.

6. TERM OF CONTRACT:

The anticipated contract term is June 30, 2019 through June 29, 2021. “Year One (1)” of the

contract period runs from the effective date through June 29, 2020. “Year Two (2)” of the

contract period will run from June 30, 2020 through June 29, 2021. A yearly work plan and

budget are required.

7. NON-APPROVED USE OF FUNDS:

The CDPP will not be able to fund programs that are not part of a strategic plan that addresses the

above Category A and Category B strategies. Below is a list of examples of activities and other

items that are not allowable under the grant. This list is not all inclusive and all programmatic

activities must be approved by the CDPP.

7.1 Programs funded through other sources; supplanting funds.

7.2 Provision of professional development by unqualified individuals or use of programs that

do not have a strong evidence-base e.g., promoting a specific dietary supplement or for-

profit exercise program. Programmatic activities must be approved by the grantor.

7.3 Capital construction projects or purchase of building or other long-term funds.

7.4 Purchase of equipment other than standard consumable office supplies.

7.5 Payment of expenses for lobbying.


8. TIMELINE:

April 1, 2019 RFA opens

April 15, 2019 Optional bidders’ call, 11:00 AM – 12:00 PM

April 23, 2019 Last day to submit questions

May 3, 2019 Applications due by 11:59 PM (MST)

May 24, 2019 Applicants notified in writing of acceptance/rejection

June 30, 2019 Estimated start of contract

9. RESERVED RIGHTS:

The CDPP reserves the right to:

9.1 Reject any or all applications received in response to this RFA;

9.2 Not make an award to any applicant who is not in good standing at the time a contract is

awarded;

9.3 Withdraw the RFA at any time, at the agency’s sole discretion;

9.4 Make an award under this RFA in whole or in part;

9.5 Negotiate with the successful applicant within the scope of the RFA in the best interests of

the State;

9.6 Disqualify any applicant whose conduct and/or application fails to conform to the

requirements of this RFA;

9.7 Seek clarifications and revisions of applications;

9.8 Use historic information obtained through site visits, business relationships, and the State’s

investigation of a bidder’s qualifications, experience, ability or financial standing, and any

material or information submitted by the bidder in response to the agency’s request for

clarifying information in the course of evaluation and/or selection under the RFA;

9.9 Amend the RFA to correct errors or oversights, or to supply additional information as it

becomes available;

9.10 Change any of the scheduled dates;

9.11 Eliminate any mandatory, non-material specification that cannot be met by all of the


prospective applicants;

9.12 Waive any requirement that is not material;

9.13 Conduct contract negotiations with the next responsible applicant, should the CDPP be

unsuccessful in negotiating with the selected proposer;

9.14 Utilize any and all ideas submitted in the applications received;

9.15 Require correction of simple arithmetic or other apparent errors for the purpose of assuring

a full and complete understanding of an application and/or to determine an applicant’s

compliance with the requirements of the solicitation; and

9.16 Cancel or modify contracts due to the insufficiency of appropriations.

10. APPLICATION REVIEW PROCESS:

Applicants will be evaluated based upon the weighted evaluation factors described in Appendix

A. A group of reviewers will be established to evaluate all completed applications and make

recommendations based upon final scores. The CDPP may contact an applicant for clarification

or questions related to the application.


APPLICATION

1. GENERAL FORMAT REQUIREMENTS:

Applications must follow the general requirements when submitting to this RFA:

1.1. Application must be typed in Times New Roman, no smaller than 11 point font, with 1 inch

margins on standard paper (8.5” x 11”).

1.2. Applications must be organized by sections (in bold) labeled below.

1.3. Applications must be submitted as a single PDF file and include all application requirements.

2. APPLICATION REQUIREMENTS:

2.1. Cover Sheet. Please include the following applicable information in your cover sheet: (1

page maximum)

a. Name of Applicant Organization (as registered with the Wyoming Secretary of State)

b. Tax ID

c. DUNS Number

d. Physical Address of Applicant Headquarters

e. Mailing Address of Applicant Headquarters (if different)

f. Website of Applicant

g. Name of Contact Person

h. Title of Contact Person

i. Phone of Contact Person

j. Fax of Contact Person (if available)

k. Email of Contact Person

l. Name of Authorized Signatory Person

m. Title of Authorized Signatory Person

n. Email of Authorized Signatory Person

2.2. Organizational Experience. Describe the organization’s experience related to the below

requirements. (10 pages maximum)

a. Chronic Disease. Describe the organization’s experience and expertise in working in

chronic disease prevention and management, specifically type 2 diabetes prevention,

diabetes management, and heart disease prevention through the management of blood

pressure and blood cholesterol. Specifically discuss experience with evidence-based

community programs (e.g. the National Diabetes Prevention Program, Diabetes Self-

Management Program, Chronic Disease Self-Management Program, etc.).

b. Public Health. Describe the organization’s experience and expertise in working in public

health prevention, to include conducting state and community needs and resource

assessments; community mobilization and coalition building; the strategic planning


process; implementing strategies and activities with fidelity; and evaluating

programmatic and systems outcomes.

c. Evidence-Based Program Implementation. Describe the organization’s experience and

expertise in implementing evidence-based programs and interventions on a policy,

system, and environmental level.

d. Communications and Media. Describe the organization’s experience and expertise in

developing and implementing regional and community-level media campaigns that are

specific to hypertension awareness, cholesterol awareness, prediabetes and diabetes

awareness, and promote referrals to chronic disease self-management and prevention

programs.

e. Professional Development. Describe the organization’s experience and expertise in

providing professional development opportunities to healthcare professionals,

specifically around high blood pressure, high cholesterol, prediabetes, and diabetes.

f. Technical Assistance. Describe the organization’s experience providing technical

assistance to organizations, individuals, and community partners in program

implementation.

g. Community-Level Relationships. Describe any relevant experience in organizing and

working with community-based organizations/businesses, prevention and wellness

coalitions, non-profit organizations, health systems, businesses and worksites, primary

care providers, hospitals, clinics, pharmacies, local and state governments, etc.

h. State-Level Affiliations. Describe any relevant experience the organization has in

working or collaborating with statewide councils, collaborators and groups. Additionally,

describe any relevant experience the organization has in working with governmental

agencies and organizations such as the Wyoming Department of Health, Public Health

Programs (e.g., Prevention and Health Promotion Unit, Maternal and Family Health, and

Public Health Nursing); Department of Education; Department of Transportation;

Governor’s Office; and Department of Family Services.

2.3. Organizational Capacity. (5 pages maximum)

a. Knowledge and Ability. Describe the organization’s knowledge of chronic disease

prevention and management, including ability to stay up to date with best practices and

current disease guidelines. Additionally, speak to the organization’s knowledge of

Wyoming culture. Demonstrate how this knowledge will be applied toward proposed

work plan activities.

b. Project Management. Describe the organization’s experience with projects similar to the

scope of this project. Describe how the organization has or would obtain adequate

regional resources prior to June 30, 2019. Describe the processes for timely

communication among staff and program personnel.


c. Staff Capacity. Describe the organization’s existing capacity to dedicate the equivalent

of a minimum of one (1) full-time equivalent (FTE) to the implementation of project

deliverables. One (1) FTE may be split up between multiple staff if desired. If

organization does not have existing staff capacity, describe the plan and timeline to hire

sufficient staff for project implementation.

d. Challenges. Describe any challenges that may arise in building and/or maintaining

capacity to complete project deliverables. Also, include possible solutions to the

challenges, if applicable.

e. Billing Processes. Describe tracking and billing processes that ensure billing is kept

separately for this project and is implemented in accordance with Generally Accepted

Accounting Principles (GAAP).

f. Organizational Chart (not included in page limit). Provide an organizational chart (if

applicable) demonstrating where and how this program will fit into the organizational

structure and staffing patterns.

g. Quality Improvement. Describe both internal and external organizational quality

improvement processes. Describe how the organization will monitor services to ensure

that they are provided in accordance with contractual obligations and make adjustments

as necessary. Describe the organization’s ability to collaborate with a CDC-recognized

organization to identify and implement strategies to address at least one social

determinant of health which supports improving enrollment and program retention

among the targeted patient population.

h. Conflicts of Interest. Describe any conflicts of interest (actual or through inference)

related to this program or any other WDH program.

i. Lobbying Disallowed. Describe how the applicant will ensure that staff hired in

relationship to this project will not: a) personally or organizationally attempt to influence

government officials or elected representatives in regard to appropriation(s), legislation

or legislative policy; b) attempt to induce anyone else to influence government officials

or elected representatives in regard to appropriation(s), legislation or legislative policy;

c) permit the use of any grant funds in an attempt to influence a government official or

elected representative in regard to appropriation(s), legislation or legislative policy at the

local, state, or federal level to include personnel service (i.e. lobbyist), telegram,

telephone, letter, email or web correspondence, printed or written matter (e.g., kit,

pamphlet, booklet, or publication), or any other device (e.g., radio, television or video

presentation), or other mechanisms.

2.4. Proposed Project Work plans. Describe the organization’s approach to performing the

below requirements during year one (1) and year two (2) of the funding period. Year one (1)

may be used as a capacity-building period. (10 pages maximum)


a. Project Abstract. Provide a project abstract summarizing plans for the upcoming two-

year period that will support chronic disease prevention and control efforts in

Wyoming. Project activities should be tied to strategies listed in the Rationale section

of this RFA. Applicants are required to propose activities for a minimum of three

strategies under Category A and a minimum of three strategies under Category B. At

least one evidence-based intervention should include collaboration with a health

system. Topics for year one (1) and year (2) may differ, but should include evidence-

based interventions, such as policy, systems, and environmental, community-clinical

linkages, or health systems change.

b. Partnership Building. List your history of supporting partnerships and collaborative

stewardship, as well as your history of relationships between health systems and

community programs. Describe your experience developing positive relationships with

different kinds of people and groups. What are the primary existing partnerships or

collaborations that you want to maintain and nurture within your geographic area?

Describe three (3) activities sponsored by an external partner that your organization

actively engaged and participated in. Applicants must address how they will

incorporate lessons learned from past experience into their current work.

c. Professional Development. Applicants should include a plan of action on how they will

provide professional development to providers on best practices related to team-based

care. Applicants awarded this funding opportunity will be required to (1) present at an

annual meeting to inform and encourage participation in medication management and

DSMES in the pharmacy setting; (2) promote Million Hearts toolkit materials through

regional professional development opportunities and relevant medical conferences; and

(3) provide professional development and education on referring to appropriate

Chronic Disease Self-Management Program (CDSMP) in Wyoming communities.

d. Technical Assistance. Describe your plans to work with health systems and providers

to increase referrals to and use of the National DPP. How do you plan to work with

health systems to improve the quality of care to underserved populations with the

highest hypertension and prediabetes disparities? Include a plan of action to establish

and maintain a multi-disciplinary steering committee to provide leadership and

guidance in implementing, sustaining, and monitoring program effectiveness in

increasing engagement in medication management and DSMES in the pharmacy

setting.

e. Communications and Media. Describe your plan to design, develop, and implement a

strategic marketing and communications plan and public relations campaigns that, in

collaboration with CDPP, will:

1. Promote awareness of both prediabetes and the National DPP throughout

Wyoming underserved areas which includes:

Community outreach

Communications campaigns

Identification of key target audiences and tactics for each


2. Strengthen relationships with community partners to promote the American Medical

Association Prevent Diabetes STAT: Screen Test Act Today toolkit to health systems

and providers in the state.

Implement screening and identification systems for people with

prediabetes

Identify patients with undiagnosed hypertension

Engage in marketing, recruitment, and referral activities to build public

participation/enrollment in the DPP.

3. Increase local awareness and participation in the National DPP and Million

Hearts Hypertension Control Challenge at the provider level.

4. Increase systematic referrals of adults with hypertension and/or high blood

cholesterol and prediabetes to community programs and resources.

5. Support a comprehensive strategy for enrolling pharmacists into the Integrated

Pharmacy Project to encourage use of the Pharmacists' Patient Care Process

(PPCP) and collaborative practice agreements (CPA) in chronic disease

management.

f. Data Collection and Reporting. Describe data collection plans including regional

assessments, survey, and evaluation plans for proposed work plan interventions.

Applicants will be required to address a social determinant of health that is an identified

barrier to enrollment and retention in the program; and collect and report data on

process and outcome measures relevant to experiences of the targeted population in

achieving goals, and assess the impact of interventions taken. Must submit performance

measure data and progress report to CDPP quarterly, including:

A steering committee membership roster.

Summary of steering committee actions taken and/or planned individually or

collectively to support the DPP and the Integrated Pharmacy Project.

Number of people reached through DPP marketing/communications efforts (ex:

counts of marketing materials distributed, number attending promotional events

or touched through outreach, reach of advertising, media impressions, etc.).

Number of people who enroll in DPP categorized by highest risk, diabetes status

and/or priority population status whenever possible.

2.5. Evaluation. Describe your plans to implement a multi-level evaluation system to ensure

continuous quality improvement and ongoing methods for monitoring the progress of your

proposed program. This section must include the methods, techniques, and tools used to: 1)

monitor whether the work plan is being implemented as planned, as well as identify processes

for corrective actions if necessary; 2) monitor and track progress on the proposed outcomes

and objectives; 3) ensure data is collected and reported in a timely and accurate manner; and

4) compile a final report summarizing the implementation and final outcomes of regional

activities. (4 pages maximum)

2.6. Budget Narrative. Using the template, provide a breakdown of the proposed year one (1)

and year two (2) budget and justification narrative for this project that clearly details the costs

for all projects and major deliverables for the project period, not to exceed $196,800 for


Regions I-V, and $120,000 for Region VI. Salary/Personnel cost including fringe should not

exceed $65,000 per year without justification.

Indirect costs should not exceed ten percent of the budget subtotal.

Funding through this grant opportunity may not supplant existing activities in any way,

nor are these funds to supplant projects that were previously funded through another

source.

Budget should include travel for contractor to attend one (1) three (3)-day chronic

disease conference each year and one (1) four (4)-day CDPP training event/meeting

each year. Both events will be held in Wyoming.

In addition to completing the budget template, provide a written detailed description of any

cost sharing sources by name and estimated amount for years one and two. Discuss the

percentage cost sharing that the organization will offer to ensure collaborative support for

project goals. Document the process used for determining the value of non-cash cost sharing

funds for documenting the actual cost sharing received.

Additional Salary/Personnel support through cost sharing is allowed.

Expense

Category Item Description Justification

Estimated Cost

for Term of

Grant

Personnel

Salary

Fringe

Contracts

Consultants

Equipment

Supplies

Travel

Indirect

Other

(specify)

Total Cost:


2.7. Letters of Commitment. Provide a minimum of two (2) letters of commitment from any key

partners identified in your project work plan. Letters of commitment should specify how the

partner will work with applicant organization on activities proposed in this application.


CERTIFICATION OF AUTHORIZATION

By submission of an application, the proposer certifies:

Prices in this proposal have been arrived at independently, without consultation, communication or

agreement for the purpose of restricting competition.

No attempt has been made nor will be by the proposer to induce any other person or firm to submit,

or not to submit, a proposal for the purpose of restricting competition.

The person signing this proposal certifies that he/she is authorized to represent the company and is

legally responsible for the decision as to the price and supporting documentation provided as a

result of this advertisement.

Proposer will comply with all federal and state regulations, policies, guidelines and requirements.

Prices in this proposal have not been knowingly disclosed by the proposer and will not be prior to

award to any proposer.

I certify to the best of my knowledge that the information contained in this application is correct. If

awarded funding under this grant, I certify that this project will be conducted in accordance with

funding source requirements and the assurances provided within this application.

I have been authorized by the agency’s governing body to submit this application.

___________________________________________ __________________

Signature of Authorized Agent Date

___________________________________________

Name of Authorized Agent


APPENDIX A:

Component of Application Points

Available

Cover Sheet 2

Organization Experience 13

Organization Capacity 15

Proposed Project Work Plan 30

Evaluation 15

Budget Narrative 10

Letters of Support 15

Total Possible Points 100

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